How to get paid for genicular knee INJECTIONS

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Understanding the Genicular Nerves (image below)

Do you remember the struggle when we didn't have the specific code for the Genicular Nerve Knee Block and for the ablation or the RFA? Prior to January 1, 2020, we used to code them using 64450 for the Peripheral Nerve Block and the you used the 64640 for the Ablation. Not only that, you need to know the nerves that were blocked or were RFA'ed.
 
But Effective January 1, 2020, we have now a specific code for the Genicular Nerve Knee Block and the Genicular Nerve Knee Ablation. You can read more about that change in our blog. CLICK HERE.

CPT 64454 Genicular Nerve Block
Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed

CPT 64624 Genicular Nerve Ablation or RFA
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed

Unfortunately many of our Pain and Orthopedic Physicians are still struggling getting reimbursed for these services even though we already have these specific codes in place since 2020. And why is that?

There are common issues why:
1) Their billing staff are still using the old codes CPT 64450, CPT 64640 instead of the CPT Code 64454 and 64624 for the Genicular Nerve Block and Radiofrequency Ablation;
2) What I found is that, this is considered as Investigational and Experimental based on the following guideline when being reported:

Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including but not limited to any of the following:

• Degenerative joint disease;
• Osteoarthritis of the knee;
• As a treatment prior to knee replacement;
• As a treatment following knee replacement;
• As a treatment for individuals who are not candidates for knee replacement surgery.

But I have also read that there are two CMS Contractors who covers for this procedure based on Medical Necessity. See Group 1 Diagnosis Codes Cross Over:

Group 1 DX Codes:

• M25.561 Pain in right knee
• M25.562 Pain in left knee

Read more about guidelines:
National Government Services Inc Billing and Coding: Peripheral Nerve Blocks (A57452)
First Coast Service Options, Inc Billing and Coding: Peripheral Nerve Blocks (A57788)

More Guidelines from Payers which consider the procedure to be Investigational:
Aetna Healthcare
Anthem Blue Cross Blue Shield

How do you handle Denial and Appeal for Genicular Nerve Ablation or Genicular Nerve Block?
Here are my tips:
Avoid the denials in the first place! by knowing your payers' guidelines;
If the Provider says its Medically Necessary for the patient to receive the genicular nerve block or genicular nerve ablation, try getting a Predetermination based on Medical Necessity from your Payer! They will not allow you to submit Prior Authorization because for sure, it does not need Prior Authorization because its not a covered benefit based on their policy because the payer considers it "investigational" or "experimental"; Insist on reviewing Predetermination based on Medical Necessity instead!
Already having denied claims? - pursue the claims by sending appeals, get your patient get involved with the appeals process. Be prepared with your medical documentation! How's the Patient's Pain Relief? Duration of Pain Relief? Improved ADL? - include that all in your documentation!
Searched Keywords: GENICULAR NERVE BLOCK DENIAL AND APPEAL CPT BILLING CODE 64454

HOW TO GET PAID FOR GENICULAR NERVE KNEE INJECTIONS

Need help how to Appeal your claims? Contact Us today!
Need help how to obtain Pre-determination before you render the Genicular Nerve Block to your patients? You should contact us today!